GreenField Health’s Health Matters: April 2006
Transformation at GreenField—Spring Session Still Open
Welcome to Lindy Thornbloom and Heidi Downey
Generic Medications
Treatment of Menopausal Hot Flashes
Fatigue
Women and Heart Disease
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Transformation at GreenField—Spring Session Still Open
We are actively working to fill our Spring Transformation session – the results from the first two groups have been amazing! As a reminder, Transformation: The GreenField Health Weight and Lifestyle Management Program is specifically designed to help participants learn skills and strategies to regain a healthy lifestyle and appropriate, sustained weight loss.
The initial session consists of an intensive Friday night and Saturday session followed by six in-depth weekly 2.5 hour meetings. Content includes physical evaluation, health assessments, diet and fitness instruction, menu planning, individual goal-setting, shopping education and discussion of the emotional aspect of our diet and exercise habits. This is followed by 16 weekly check-ins to evaluate progress and to reassess each individual’s personal program. The second half of the program will also include monthly meetings of the group to discuss specific health or exercise topics in greater detail.
Participants also receive more than $200 worth of tools to support weight management. The program cost is $995. Please contact Cynthia Ferrier, MD at 503-292-9560 or Cynthia.ferrier@greenfieldhealth.com to sign up in advance if you are interested as space is limited.
Welcome to Lindy Thornbloom and Heidi Downey
A warm welcome to Lindy Thornbloom and to Heidi Downey – two of GreenField’s newest team members. Lindy joins us to work both as a Health Coordinator, and to assist with our billing, so you may have the chance to talk with her on either topic. She comes to us with many years of medical office experience, and we are delighted to have her.
Heidi joins us having spent many years on the IT side of things – we first met her when she was doing implementations for our medical records software company, and she will now be working with us to improve our use of the product internally, and to grow our consulting business. We continue to push the use of technology within our office so that we are leveraging the tools we have here for the best possible patient care. We are excited to have Heidi as a part of the team to help us along this path!
Generic Medications
We have discussed generic medications in the past. In the vast majority of cases, the generic version of a medication is as good as the brand name, and is much less expensive. There is rarely a reason not to use a generic when one is available. Generic pharmaceutical manufacturers have to meet the same stringent federal standards as other pharmaceutical manufacturers.
It is difficult to predict exactly when a generic will be released. Patents in the US usually last 20 years. However, by the time a new drug reaches the market, it typically has only about 10 years of patent protection left. As the end of a patent approaches, there is significant legal maneuvering between brand and generic manufacturers to both challenge patents and protect them. For example, generic versions of Fosamax (alendronate), Sonata (zaleplon), and Wellbutrin XL (extended release bupropion) are currently stuck in the courts.
The upcoming year will see a large number of expensive brand-name medications go generic. This is fantastic if you have to pay out of pocket for your medications. Below is an example of medications that will become generic in 2006. We only list those that are most commonly used. They are listed by the brand name with the generic name in parenthesis.
• Altace (ramipril): an angiotensin-converting enzyme (ACE) inhibitor blood pressure medication
• Amaryl (glimepiride): a sulfonylurea oral diabetes medication
• Ambien (zolpidem): a non-benzodiazepine sedative used for insomnia
• AndroGel (testosterone topical gel): used for men with testosterone deficiency
• DynaCirc (isradipine): a calcium channel blocker blood pressure medication
• Flonase (fluticasone nasal spray): a nasal steroid spray used for seasonal allergies
• Metaglip (glipizide and metformin): a combination of oral diabetes medications
• Pravachol (pravastatin): a cholesterol-lowering “statin” medication
• Proscar/Propecia (finasteride): a medication for shrinking the prostate use in men with benign prostate enlargement
• Xanax XR (alprazolam extended release tablet): a benzodiazepine sedative used in anxiety disorders
• Zithromax (azithromycin): an antibiotic frequently used for upper respiratory infections
• Zocor (simvastatin): a cholesterol-lowering “statin” medication
• Zofran (zofran): an anti-emetic medication used to treat nausea and vomiting
• Zoloft (sertraline): a selective serotonin reuptake inhibitor (SSRI) antidepressant
In 2007, the following medications are due to lose their patent and thus go generic:
• Coreg (carvedilol): a beta-blocker blood pressure medication
• Lamisil (terbinafine): an oral antifungal medication frequently used to treat fungal infections of the toenails
• Norvasc (amlodipine): a calcium channel blocker blood pressure medication
• Zyrtec (cetirizine): a non-sedating antihistamine used for allergies
New generics will trigger formulary changes and therapeutic switches by insurance companies. For example, some plans will require using generic Zocor (simvastatin) instead of brand Lipitor for cholesterol lowering or generic Ambien (zolpidem) before brand Sonata or Lunesta for insomnia.
We generally attempt to prescribe generics whenever they are available, but don’t hesitate to ask us just to be sure. Also, you can ask your pharmacist if you are unsure if a generic equivalent is available.
Treatment of Menopausal Hot Flashes
Last year, the Women's Health Initiative found that taking estrogen plus a progestin for more than 5 years increased the risk of cardiovascular disease and breast cancer. This instantly changed the way hormones are used in menopausal and post-menopausal women. Almost overnight, the tendency went from using hormone replacement quite liberally to using it quite judiciously.
Another recent study now suggests that the increased cardiovascular risk is quite small with short term estrogen replacement in women. This finding gives comfort to women and their physicians who want to use estrogens on a short term basis, since estrogen is by far the most effective treatment for ameliorating menopausal hot flashes.
Women taking an estrogen replacement who have not had a hysterectomy should also take an oral progestin to prevent estrogen-induced excess endometrial growth and cancer. Estrogen alone is available as a pill, a transdermal patch, a topical gel and intravaginal gel. Combined estrogen and progestin products are available in oral or transdermal forms. Low-dose combination oral contraceptives are also effective.
Progestins alone are somewhat effective for the treatment of hot flashes in women who cannot take estrogens such as those with a history of blood clots or breast cancer, but problems such as vaginal bleeding and weight gain can limit their use.
What non-hormonal treatments are available? Other treatments that have been tried for menopausal hot flashes include lifestyle changes, antidepressants, alpha-2 agonists, anticonvulsants, phytoestrogens and other dietary supplements.
Several common-sense lifestyle changes can help including dressing in layers so that you can adjust your temperature easily, smoking cessation, and weight loss. Relaxation techniques such as biofeedback and meditation have also been shown to decrease symptoms.
SSRI (selective serotonin reuptake inhibitor) antidepressants such as Prozac (fluoxetine) and Paxil (paroxetine) can provide modest improvement with hot flashes, as can certain blood pressure medications such as Catapres (clonidine) and the anticonvulsant Neurontin (gabapentin). Each has potential side effects as well, but they may be worth considering when a woman does not wish to take hormones.
Unfortunately, other treatments have not proven particularly effective for hot flashes. Vitamin E, phytoestrogens (isoflavones), and black cohosh are also commonly used, but clinical trials have failed to demonstrate a positive effect.
So what should you do? Lifestyle modification such as cooling measures and relaxation techniques may be helpful for mild hot flashes. For severe symptoms, estrogens provide the most effective treatment and are probably relatively safe if administered for short periods of time. All other non-hormonal therapies are only marginally better than placebo although SSRI antidepressants, clonidine, and gabapentin may be worth considering. Women (and their husbands!) can be reassured that hot flashes will decrease with time even without treatment.
Fatigue
As you might imagine, complaints of fatigue are extremely common. Almost everyone feels more fatigued than they would like at times. The busy-ness of life makes many feel overly fatigued on a regular basis.
Fatigue refers to a feeling of exhaustion during or after usual activities or the feeling of having inadequate energy to begin an activity. Both definitions describe “feeling” a lack of energy – fatigue is subjective and should be distinguished from shortness of breath, excess sleepiness, true muscular weakness, and a reduction in exercise tolerance.
Concerns about fatigue are frequently expressed to us during office visits. People tend to worry about having a medical cause for their fatigue. Of course, fatigue is a common part of many medical conditions, but fatigue is also just so common that a prudent approach to evaluating it is important.
The initial step in evaluating fatigue is a thorough history and physical exam. Medical and psychological conditions that can present as fatigue include anemia, depression, panic disorder, thyroid disorders, and adverse effects of medications such as sedatives, muscle relaxants, antidepressants, and opioid pain medications. A careful history and physical exam will frequently suggest these problems allowing for a targeted laboratory evaluation or treatment course.
However, it is very common for individuals to feel temporarily fatigued without any accompanying physical complaint or underlying clear physical or psychological cause. The “cause” of this common feeling of fatigue is frequently just labeled “psychosocial” –meaning that the feeling of fatigue is caused by or is a reaction to psychological and/or social stresses in life. Examples include problems at home or at work, a job change, and illness of a loved one.
Laboratory tests in the absence of a suggestive history or physical examination tend to be of little diagnostic use in evaluating the fatigued individual, but we frequently check screening tests to rule out illnesses. Reasonable studies to obtain include a complete blood count, an erythrocyte sedimentation rate or “sed” rate to look for inflammatory disorders, a thyroid stimulating hormone (TSH) to screen for thyroid disorders, a chemistry or metabolic screen including liver function tests, and a serum creatine kinase looking for muscle injury. A test for HIV or tuberculosis might be considered in a high risk population. In menstruating women, it may be appropriate to check iron levels even in the absence of anemia since treatment with iron has been found to help some non-anemic women who have a low serum ferritin – a test of the body’s iron stores.
In most cases that we see, these tests are normal and the fatigue goes away without a specific explanation. The good news is that if a cause is not readily identified on history, physical exam, or laboratory screening, the fatigue generally resolves on its own.
When does fatigue become “chronic fatigue?” Chronic fatigue refers to truly debilitating fatigue lasting over six months, but it does not necessarily imply the presence of the “chronic fatigue syndrome.” The formal definition of chronic fatigue syndrome is unexplained, persistent or relapsing fatigue that is not alleviated by rest, and that significantly interferes with occupational, educational, social, or personal activities and is accompanied by four or more of the following persistent or recurrent symptoms: impairment in short term memory or concentration, sore throat, tender cervical or axillary lymph nodes, muscle pain, multi-joint pain without redness or swelling, headaches of a new pattern or severity, un-refreshing sleep, or post-exertional malaise lasting more than 24 hours.
If debilitating fatigue persists for over six months but does not meet criteria for chronic fatigue syndrome, it is termed nonspecific or “idiopathic” chronic fatigue. However, while some say that it is important to distinguish chronic fatigue syndrome from nonspecific, idiopathic chronic fatigue, the disability rates and health care utilization in these individuals is similar, so making the distinction generally is not helpful. Nonspecific chronic fatigue may represent part of the spectrum of a continuum of illness that includes the chronic fatigue syndrome.
As stated above, any individual with persistent fatigue should have a thorough history, physical exam, and laboratory screening before being given the label of idiopathic chronic fatigue or chronic fatigue syndrome. In both of these situations, the cause is currently unknown. In both chronic fatigue syndrome and nonspecific chronic fatigue, the laboratory evaluation will be completely normal. This is quite distressing because the person suffering from debilitating fatigue desperately wants to identify a cause. It is important that the individual suffering from chronic fatigue have confidence that a rational, stepwise approach to the evaluation has been taken.
The prognosis in both the chronic fatigue syndrome and idiopathic chronic fatigue is not generally favorable because the fatigue may last for years. Regardless of the long-term prognosis, neither the chronic fatigue syndrome nor idiopathic chronic fatigue results in organ failure or death.
For chronic fatigue without an identifiable cause, no known medical therapy will help alleviate the fatigue. Cognitive behavior therapy can be used to alter beliefs and behaviors that might delay recovery and regular physical exercise can be helpful, but neither is curative. A trial of antidepressant drugs should be offered to patients whose illness has features of depression, regardless of whether strict criteria for depression have been met.
Again, the good news is that, while feelings of fatigue are common, a good history, physical exam and laboratory evaluation are frequently effective at identifying the cause and when that is not the case, the fatigue generally resolves on its own.
Women & Heart Disease
Save the date to join us for a presentation by Janice Isenberg, LCSW on living with heart disease on Tuesday, May 23rd at 6:00 pm in our office.
With Our Thanks
As we continue to work on improving our systems to better serve you, our patients, we are thankful for the support and feedback you always provide for us. We are deeply appreciative of the opportunity to walk with you along your healthcare journey.
Thanks to our corporate partners
Kryptiq Corporation
Baker-Ellis Asset Management, LLC
Stahancyk, Gearing, Rackner, & Kent Law Firm
Go to our website to learn more about these corporate sponsors https://securemail.greenfieldhealth.com/Portal/General+Info/Corporate+Partners/Default.aspx
First Tuesday Reminder
The
schedule for our upcoming GreenField Health First Tuesday Open House is May 2nd, June 6th and July 4th. This is a good introduction to our
practice for relatives, friends or coworkers who might be interested in
becoming a GreenField patient. The sessions begin promptly at 5:30 PM
on the first Tuesday of each month. Learn more about our First Tuesday
Open House Online at: https://securemail.greenfieldhealth.com/Portal/General+Info/First+Tuesdays/default.aspx
Sincerely,
Your GreenField Health Team:
Beth Davis, your Benefits Coordinator and Biller- beth.davis@greenfieldhealth.com
Chuck Kilo, MD - chuck.kilo@greenfieldhealth.com
Cynthia Ferrier, MD - cynthia.ferrier@greenfieldhealth.com
Dia Gaede, CMA, your Health Coordinator - dia.gaede@greenfieldhealth.com
Elizabeth Hays, MD - elizabeth.hays@greenfieldhealth.com
Eric Murray, MD - eric.murray@greenfieldhealth.com
Heidi Downey, your Consultant - heidi.downey@greenfieldhealth.com
Jill Arena, your Clinic Administrator - jill.arena@greenfieldhealth.com
Joel Swartzmiller, IT Manager - joel.swartzmiller@greenfieldhealth.com
Lindy Thornbloom, your Health Coordinator - lindy.thornbloom@greenfieldhealth.com
Pam Mockenhaupt, CMA, your Health Coordinator - pam.mockenhaupt@greenfieldhealth.com
Paula Koeller, MD - paula.koeller@greenfieldhealth.com
Shelly Banta, your Clinic Manager - shelly.banta@greenfieldhealth.com
Tiana Schmitt, CMA, your Health Coordinator - tiana.schmitt@greenfieldhealth.com
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GreenField Health System
9427 SW Barnes Road,
Suite 590
Portland,
OR 97225
Phone: 503-292-9560
Fax: 503-292-9510
Web: http://www.greenfieldhealth.com
Questions, concerns, comments appreciated:
questions@greenfieldhealth.com
copyright 2003-2006 GreenField Health
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